WRITTEN STATEMENT REGARDING SECTION 223(d)(5)(C) OF THE SOCIAL SECURITY ACT – DO NOT REMOVE I, [Name and Title], am an excluded medical source because I was convicted of a felony under section 208 or 1632 of the Social Security Act on [Date of Felony Conviction].
| File Type | application/pdf |
| Author | ALC |
| File Modified | 2016-06-16 |
| File Created | 2016-06-16 |